VICKIE L. POTTS				

				Charlotte County Tax Collector		BIDDER NO.___

									TAX YEAR____

				BIDDER REGISTRATION FORM



PLEASE PRINT: 	Enter your name as you want it to appear on the tax certificate.

		Enter additional names in the address portion.



NAME____________________________________________________________________________

	(Last Name First)

ADDRESS__________________________________________________________________________



	___________________________________________________________________________



	___________________________________________________________________________



CITY________________________________STATE__________________ZIP___________________



PHONE______________________________EXT____________________



SOC.SEC #________  _______  _________OR TAX ID # ____________________________________

			Identification # of person on name line

SIGNATURE________________________________________________DATE__________________



E-MAIL ADDRESS____________________________________________